Fillable MDR Tracking No - tdi texas

Texas Department of Insurance, Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 MEDICAL DISPUTE RESOLUTION FINDINGS AND DECISION PART I: GENERAL INFORMATION Type of Requestor: (x) Health Care Provider Requestor s Name and Address: ( ) Injured Employee ( ) Insurance Carrier MDR Tracking No.: Claim No.: Injured Employee's Name: Date of Injury: Employer's Name: Insurance...
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